The future of oncology: more of the same?

Abstract

R eminiscent of President Kennedy's pledge in the early 1960s to land a man on the moon within the decade, in 1971 US President Richard Nixon declared a war on that was to eradicate the disease within that decade. Researchers and politicians have since become more prudent about the promises they make, but similar euphoric projections continue to be issued in conjunction with announcements of breakthroughs in Today, these are more likely to be targeted at the stock market than at the scientific community, and the public has become increasingly sceptical. In reality, improvement in the cure rate has been minimal over the past 15 years, despite the unprecedented amount of new information about the biology of cancer. The rise in cancer mortality is due more to the higher incidence of neoplasms that occur subsequent to survival of other diseases, and overall longer survival, than to the real, age-adjusted higher incidence of some tumours (eg, melanomas, lymphomas, lung cancers). In the early years of the new millennium a third to a fourth of all deaths will be cancer-related, at least in the developed world. Does this imply that no major therapeutic progress can be expected for the next 10-20 years? Not necessarily. Although the improvement in the cure rate of some tumours Cancer cell in the 1960s and 1970s was due chiefly to technological factors (surgical techniques, highenergy equipment in radiotherapy, the empirical discovery of new drugs such as cisplatin), the next major step forward will probably come from the biological revolution, of which the discovery of the BRCAI and BRCA2 genes in breast cancer is only the beginning. In coming decades, the availability of individual cancerrisk assessment based on molecular genetics will render a much more individualised approach to preventive measures: changes in lifestyle are easier to achieve when people are confronted with a personal as opposed to a population-based risk assessment. The flipside of the coin, however, is the possibility that this evolution will generate more bad than good news. Lifestyle changes can in fact prevent the occurrence of only some tumours, and it is currently impossible to predict when chemopreventive agents are likely to become available (current results with tamoxifen are much too preliminary). Meanwhile, the most immediate consequence of greater clarification of molecular genetics, and of the advent of novel tumour markers, could simply be an increase of anxiety in individuals at risk. Such developments will ultimately lead to an improved cure rate, but they could also dramatically increase the number of cases without a clear localisation of the primary tumour. It is difficult to see how such patients could then be treated with the current cytotoxic chemotherapies, The future of oncology: more of the same?